Benign pneumatosis intestinalis with massive portomesenteric venous gas in a very old man. A case report

Introduction. Pneumatosis intestinalis (PI) is described as the presence of air within bowel wall. PI aetiology is various: it can be associated with non-urgent or life-threatening conditions. Clinical management is based on physical examination, blood tests and radiology, in particular abdominal CT. The cause of PI suggests the correct therapy.
When PI is linked to gas in portal and mesenteric venae (PMVG), bowel ischemia or infarction is possible, and surgery needed.
Case report. A 91 years-old man was admitted to Emergency Department reporting abdominal pain and vomit. Acute abdominal symptoms, radiological finding of small bowel PI with massive PMVG, severe neutrophilia, and high serum lactate forced us to perform exploratory laparotomy, from which it was observed a diffuse band-like pneumatosis of all the small bowel and mesentery without ischemic or peritonitis signs. The patient was imposed to fast and treated with oxygen, intravenous fluid and antibiotic therapy, without performing further surgery, and was discharged to a rehabilitation facility after symptomatology resolution.
Discussion. Scientific literature underlines the importance of PMVG to consider as critic a patient with PI, but it is always essential to assess also physical examination, vital parameters, and blood exams. In our case, several signs were suggestive for bowel infarction: its absence and the swift recovery of the patient were unexpected.
Conclusion. Although non-surgical treatment is recommended for primary PI of unknown aetiology, in case physical examination and radiological signs aren’t decisive surgery is necessary to rule out bowel infarction. This case stresses the difficulty of PI management.